Prime Time (with Bonus Content)

by Jane Fonda

  Can Sexual Pharmaceuticals Make

  for a Good Sex Life?

  These advances in penile enhancements and drugs may be great for many men and their partners, but Dr. Perelman, who views sexuality from a psychological as well as a physical viewpoint, says, “Restoring a man’s erectile capacity does not necessarily make for a good sex life for either the man or his partner because there is a whole range of psychosocial-behavioral-cultural issues that impact people’s sexuality. Both the men and their partners need to understand where these medications will make a difference and where they won’t.”

  They won’t help mend marital conflicts. According to Dr. Perelman, the problem in about 10 percent of the cases he sees is that the woman is not receptive, and a pill won’t help the man become a more sensitive lover so that she will become receptive. The man may come home having popped a Viagra, eagerly looking forward to the joy of putting his erect penis to good use. “Hey, honey, I took this pill, let’s go!” But women are more contextual; they need foreplay (so do older men!), and this can create conflict.

  So imagine, instead, this alternative positive scenario: The man calls ahead and says, “Sweetheart, I’ve been longing for you all day and I’m feeling like I should take the pill right now before I get home, but I want you to want it, too. What do you think about turning on some romantic music and lighting some candles so you’ll be in the mood when I get there?”

  Or the man comes home and his wife is preparing dinner at the sink. He comes up behind her and begins to kiss and nibble her neck. “How about we move to the couch and make out a little,” he tells her. “I’m hungrier for you than for dinner right now.” When he sees that she is getting turned on, he asks, “Should I go get a pill? Would you like that?”

  In these kinds of scenarios, the erection occurs within a mutual context of desire. Then, once this happens, the partner needs to let the man know what she likes him to do now that he has his erection—what positions, what speed, more foreplay, and so on. Whatever happens or doesn’t happen, why not celebrate and be grateful that your partner brought his erection home to you rather than to someone else! Perhaps thinking about that fact alone can be a turn-on.

  The Mental Aspects of Arousal

  Clearly there is a dynamic balance between mind and body, and it isn’t static. Dr. Perelman says, “Being turned on is mental and physical, and so is being turned off. Positive mental and physical factors increase the likelihood of a response, while negative mental and physical factors inhibit the sexual response.” Because women’s sexual response is generally more context-sensitive than men’s, a combination of medical and psychological treatments can be especially effective. And Jane Brody notes, “While a Viagra-like drug is not yet an option for women, use of the antidepressant bupropion (Wellbutrin at 300 milligrams a day) may improve sexual arousal and satisfaction in women who are not depressed.”1 However, numerous clinical trials are currently being conducted worldwide to identify compounds to assist women with their sexual response.

  Dr. Bill Stayton, sex therapist and former executive director of the Center for Sexuality and Religion at Morehouse School of Medicine, pointed out to me that one of the biggest culprits in sexual dysfunction is being an observer of yourself. A man may wonder, he said, “ ‘Am I going to get it up? Is it going to stay up? Is it going to come too quickly? Am I not going to come at all?’ So, on his side, you’ve got two people in bed, you’ve got the guy thinking about it and you’ve got the guy trying to do it. And then you have another two people in bed on the other side when the partner begins to think, ‘Is it me? I mean, why isn’t it working? He took the pill, what happened? Maybe he’s really not turned on by me?’ So now you’ve got four people in bed. What’s going on is between the two observers, and the two actual people in bed get shot out the window. So,” Dr. Stayton noted, “pharmaceuticals can be great if they are in a proper perspective and the person is really turned on to making love and not observing. First thing we do is kick the observers out of the bedroom.”

  Creating a combination treatment by adding counseling and education to the mix, along with the pharmaceuticals, may be what is needed to create a positive sexual tipping point for the couple. Right now, however, too few doctors may take psychosocial, behavioral, or cultural factors into account when treating sexual dysfunction. In a 26,000-person study done in 2005, “only 14% of adults in the United States reported that a physician asked about their sexual concerns within the past three years.”2 Dr. Perelman feels that ignoring the nonphysiologic factors of sexual dysfunction—such as anxiety, anger, depression, early trauma, fear of failure, loss of confidence, and relationship issues—is what lies behind the 20 to 50 percent discontinuation rates reported for current erectile dysfunction treatments. A pill is not a magic bullet.

  Erectile Function After a Prostate Operation

  I asked Dr. Perelman what the current practice is to restore erectile function in men who have had various kinds of prostate operations or radiation. “What the medical profession is doing now to help restore erectile capacity is what we call penile rehabilitation right after surgery,” he said. “The trick is to get these men getting erections as quickly as possible based on numerous theories, including one that brings blood flow and oxygen to the penis. The hope is that this will help the recovery process. So now urologists will give Viagra, Levitra, or Cialis to most men on a daily basis, or every other day, and begin to restore erections in that manner. But does restoring erections make for a good sex life? I think of it as something very helpful but not sufficient in and of itself. It depends on what else happens.”

  Male Orgasmic Capacity

  Dr. Perelman told me that for some men, sexual-enhancement drugs and implants actually create a new problem. “In general, as men age, it becomes a little more difficult to reach orgasms for the same reasons that we don’t hear as well, we don’t see as well, our touch isn’t as sensitive. The drugs are restoring their erectile capacity, but they are not helping them with their orgasmic capacity. Some guys can be kind of naive, and go, ‘I must be turned on, I have an erection,’ but they have an erection because they took a pill, or injected themselves, or they have a prosthesis”—a pump—“that is providing them with an erection. So they are presuming they are excited, and their partner might presume they are excited because, after all, he has got an erection, and maybe he hasn’t even told her he has done this. So she is thinking everything is fine, and they make love, and he is unable to reach orgasm because he may not really be excited.”

  The problem is, Dr. Perelman explained, that “he is artificially induced into an erection, which would be much the same thing as a woman who is using too much lubricant and isn’t really turned on, but she is able to have intercourse because she is so wet, the penis slides in. So men are starting to have this problem that we used to only hear about from women, about not being able to reach orgasms. Initially, the woman will feel, ‘Oh, there must be something about me, it’s my fault.’ But then she will start getting angry and we begin to see the same sort of compulsive ‘How come he’s not coming?’ that you see in some men who are dragging their wives and girlfriends in here saying, ‘I want to see her have an orgasm, a real orgasm, none of this vibrator or clitoral stuff. I want to give her one!’ The men, of course, are very distressed because it is a loss of something that was vital to both their sense of themselves as a man and their capacity. Right now I am describing probably 3 to 5 percent of men benefitting from medical assistance. I will predict for you, though, that this will be a greater percentage of individuals because it really hasn’t been documented before.”

  The sexual pharmaceutical drugs are not meant to treat delayed ejaculation. There are, as of this writing, some off-label drugs designed for this purpose but nothing that is FDA-approved.

  The Problem of Denial

  Then there’s the problem of denial. Dr. Perelman explained that the average man spends two to three years in denial about his erectile dysfunction before he
seeks help. By then a new sexual equilibrium has taken place between the couple; they may have simply adjusted to not having much sex or to having a different kind of sex or to no sex at all. “What makes things worse for many partners of these men,” said Dr. Perelman, “is that the men will begin to avoid any kind of intimacy, especially affection, because the presumption is that if they are affectionate, she may mistake this as an initiation of sex and he doesn’t want to fail. Who wants to do what they won’t do well, if you will?”

  I find it so sad that couples will deprive themselves of the sensuality of touch, of playing, of the whole cornucopia of intimate and sexy things they could do without thinking about intercourse. Almost nothing brings home to me as forcefully as this the toxic nature of masculinity as it is currently defined by our culture and internalized by men and boys. They are so vulnerable to being shamed because they might not perform the way they think they should that they and their partners miss out on pleasure.

  Communication Between Patients and Doctors

  As I have said before, simply writing a prescription isn’t enough. Erections, with no context, aren’t enough. I think many doctors need to spend more time talking with their patients so as to get a holistic understanding of the landscape of the particular relationship. Along with others in his field, especially some of the women doctors, Dr. Perelman is a big advocate of getting the partner into the consultation session. “We should see both people,” he said. “Not just the men. So, I did a little study of sexual medicine specialists who are urologists, across the country, and found out that less than one out of ten of them ever saw a partner at all, let alone every time that they saw the guy. For the most part, some of the men do not want the partner to come in, some of the men are not even telling their partners that they are going for help because they are so embarrassed about it, and in a very small percentage of cases they are not telling the partner because they plan on using it elsewhere.”

  Dr. Tom Lue told me that it isn’t that doctors don’t want to see the partners but that, very often, the partners don’t want to come in. “Interestingly,” Lue said, “if the men become impotent because of medical reasons like a prostate cancer operation, radiation, or whatever, 90 percent of the time the wife will come with the man. She will feel sympathy: ‘My man has cancer, I should help him.’ But if the man becomes impotent for other reasons—diabetes, high blood pressure, because those happen gradually—then quite often the woman thinks the man must be having an affair, or the man does not like her anymore. In those situations, the women don’t come.”

  If the partner wants to come in and the man wants her to come in, then discussing their issues together with the help of a sex therapist can lead to big changes. Consider this scenario that Dr. Perelman described: “If the man has always been insensitive to her needs and she has satisfied herself with masturbation without him knowing about it for forty years, but she always secretly hoped or was too shy to ask him to touch her, then if you can actually get her into the office and have a consultation and discover that information, and find a sensitive way of communicating that to him that doesn’t humiliate him or embarrass her, it is actually a win-win, and those are very happy people when they leave. Because now you have reestablished a new sexual script that is actually designed to satisfy her, not just to satisfy him. Then she is very happy about him getting help because she loves him, she cares for him, and a lot of things have been good in their lives, but sex was not one of them. Those situations are pretty easy to fix.”

  Medical Insurance Coverage

  As beautiful as the outcome of a couple’s sex therapy can be, a systemic problem stands in the way of this sort of therapy being broadly available. Sex therapists and urologists are concerned about managed health care and Medicare, which has meant that doctors rarely have more than six or seven minutes to talk to patients. As Dr. Perelman points out, how can the doctor, in a few minutes, “take a history, do a diagnosis, figure out what is going on with him, figure out what is going on with her? Does she need a referral to a gynecologist, does she need hormone supplementation, does she need to practice dilating herself so she might be a little more comfortable with intercourse?”

  Medical-Psychological Combination Therapy

  Understanding that just writing prescriptions and giving out pills isn’t enough for many people, Dr. Perelman wants to work with the pharmaceutical companies to develop and disseminate an easy-to-replicate, affordable model of therapy that provides both the medical options and the counseling in combination to create a sexual tipping point. He sees it applying to women as well as men, and he feels that due to the drop-off of men who regularly refill their prescriptions, the pharmaceutical companies may be motivated to fund such work. In a field dominated by penis fixers, it would be a huge paradigm shift to move into the areas of relational intimacy, especially male intimacy, which heretofore has been all but ignored.

  The Women’s Part of the Equation

  If it is the need to develop intimacy that is ignored in men, in women, especially older women, what’s ignored is understanding their sexuality. “The problem is that there hasn’t been nearly enough research done on women’s sexuality,” says Dr. Louann Brizendine, a neuropsychiatrist at the University of California, San Francisco. During our interview, Dr. Brizendine told me that several years ago she worked on a segment for CNN with one of her female patients who was around sixty-five. CNN wanted to explore the issue of women’s brain and sexual function during menopause. The news editors cut it. “They were okay with the estrogen and the ‘keeping the brain healthy’ aspects,” Dr. Brizendine told me, “but they didn’t wander into the sexual area that we had done. My patient was a little bit miffed. She felt it was really important for women to know that you can keep yourself and your body and your mind and your sexual organs healthy and have a good sex life with your partner even when you’re older and that it takes knowledge about what to do and what not to do.”

  Dr. Brizendine smiled as she related one of the best things about women she sees who have crossed the menopausal divide. “The kids are out of the house,” she said, “and they are into the next phase of their lives, and that is about how they can maintain their brain function, their sexual function, their libido. They are still very much interested in sex, but so often they come to me with very out-of-balance hormones. There has to be a hormonal balance in your brain and in your sexual organs so that all the parts are working.”

  Men’s sexual issues are visible, they are external, and they make up a large part of a man’s sense of himself, and perhaps that is partly why the research funds favor men. Women’s sexual parts are inside and may be neglected if—or as long as—doctors and researchers think that the erection is the be-all and end-all of sex. This is bad enough on a personal level, but it becomes a virtual nonstarter when it comes to studying older women’s sexuality.

  Women’s Hormone Replacement

  As you may recall, in 2000, the Women’s Health Initiative issued findings that hormone therapy (HT)—that is to say, replacing the decreasing levels of estrogen in women approaching menopause—did not prevent heart disease and, in fact, increased cardiovascular risk factors. The report hit like a bombshell and frightened untold numbers of women away from HT. In the view of the study’s critics, this has led to a generation of women suffering needlessly from menopausal symptoms, some of them acute, that could be safely treated.

  The problem, as many experts have explained it to me, was that the study was misleading because the women participants were recruited from Medicare rolls, their average age was from sixty-three to seventy-nine, many were obese or smokers or both, and some two-thirds of them had never been on hormones before and thus had been estrogen-deprived for many years leading up to the study.

  It is my understanding that the optimum time to begin HT is at menopause. Dr. Michelle Warren, medical director at the Center for Menopause, Hormonal Disorders, and Women’s Health at Columbia University Medical Center, told me, “If yo
u start HT at menopause and continue with it, there is protection against bone loss and vaginal atrophy and probably some protection against heart disease and other problems that can occur before, during, and after menopause. Some recent data also shows that the death rate is decreased in women taking hormones, and that the increase in heart attacks is not significant. Recently, they went back and saw that for the women who had been on estrogen alone, the hormones were really protecting the heart. Additionally, the study showed that in the women who were given estrogen alone as opposed to estrogen together with progesterone, there was no increase of breast cancer after almost seven years. This fact got little attention. The absolute relative risk is very small—.8 per thousand per year. I don’t think the hormones are causing breast cancer. They may be fueling the growth of some atypical cells that are present in the breast, but the risk is very, very tiny. The estrogen-responsive cancers are very responsive to treatment, and after you stop the estrogen, the risk of cancer goes away.”

  In their book Successful Aging, Drs. John W. Rowe and Robert L. Kahn cite the Nurses’ Health Study, which followed fifty-nine thousand women for sixteen years. They note, “The consensus of this research is that postmenopausal hormone replacement re-duces the risk of heart disease an average of 44 percent, and increases life expectancy by 3 years—a dramatic effect.”3 The study goes on to say, “For women with one risk factor for heart disease (such as smoking, hypertension, diabetes, or a sedentary lifestyle), the benefits of hormone replacement outweigh the risks. This holds true even for women with a first-degree relative (mother or sister) with breast cancer. However, the equation shifts for women with no risk for heart disease and two first-degree relatives with breast cancer. For these women, HT carries more risk than benefits.”4